20 April 2010

The woman in bed six informed me immediately on my arrival and introduction that she was a lesbian. I don't know why it mattered, because she was there for a scald injury on her arm, and I hadn't inquired about it. In fact, I hadn't even begun my history before she made her announcement in a somewhat belligerent tone. So ... ooookaaay. I tried not to let this non sequitur throw me too much off my stride and I went through the brief history necessary for a minor injury such as she had. As an aside, this self-proclaimed lesbian was quite feminine. She was well-dressed for the hour of the evening and quite pretty in her own sort of way. Not a butch dyke at all. She even had a choker of pearls on, along with earrings, lipstick, and well-coiffed hair.

I asked a few questions, though, and was surprised at the frankly aggressive tone of her responses. Nothing too blatant, nothing that I could call her on, but quite definite. And her story seemed to not quite add up. She reported that she had been boiling water and had burnt herself, but the burn was not consistent with a normal scald -- it was a perfect oval on the inner aspect of her right forearm, sharply demarcated. Water burns leave irregular splash marks. I commented on that fact, and asked whether she maybe had burnt herself on the pot, a suggestion to which she quickly agreed. What she was doing boiling water at midnight it did not occur to me to ask. I noted that she had been in the ER for a similar injury a month ago and asked why she was repeatedly burning herself; she explained that she had MS and was often clumsy. She was on an MS med, so that seemed to make sense.

Finally I examined the burn. Again, it was funny. The skin was a deep red, the sort of color that is associated with deep burns, which are insensate, but she was very tender and wouldn't let me touch it. The entire burn was the same color, without any variation, and without any blistering. It's really odd not to see a single blister on a wound that looks so angry.

I wandered out of the room to chew it over, and I ordered some wound care and a dressing to be applied. The nurse, Lisa, came out and informed me that the patient had refused wound care; said she had cleaned it herself at home. She wanted pain medicines, though. I commented that it was a funny-looking burn. Lisa agreed with me and smiled. "Yes doctor, it is a funny burn. She's a pretty lady, too, isn't she?"

"Well, I guess so, why do you mention it?" I responded, wondering what Lisa was getting at.

"I was just noticing how nicely she was dressed up. And her make-up. Especially the lipstick. Now that I think of it, isn't it funny that her lipstick looks the exact same shade of red as her burn? Weird." And she sashayed off.

I'm told that my expression at that moment was priceless. I went back into the room and once again the patient refused to let me touch her wound. I distracted her for moment and dragged an alcohol swab across the "burn" and, of course, the pigment came right off, revealing normal, healthy skin underneath.

I don't know how I didn't see it myself; I must need to get my bullshit detector recalibrated. The patient received a stern talking-to and eloped from the ER shortly thereafter. I got the deep satisfaction of entering a discharge diagnosis of "Malingering," which I rarely use except in bullet-proof cases.

I can only assume that she thew out the lesbian remark to put me on the defensive in the hopes that it would prevent me from looking too hard at her "burn."

You never can tell with some folks.

And I did consider calling the cops, but I didn't think I had the grounds to restrain her until their arrival, and it would have been pretty thin, since she never explicitly asked for narcotics. Also, in my experience, the local police have higher priorities than petty fraud like this.

Hi, I'm in the medical field too and was just wondering how you've managed to keep this blog up. Not to be rude, but isn't this a giant hipaa violation? I would get in serious trouble, possibly losing my job, if I ever wrote a blog like this.

1. I fictionalize every "case" I write about. They are all based on real cases, but I change a lot of details in order to ensure privacy.

2. HIPAA actually would not bar me from writing up the entire case in exacting detail. As long as I do not include any patient protected healthcare information -- specifically identifying information. That would generally include name, DOB, etc. Some HIPAA experts would say that geographic region might be enough to establish patient identity, which is why I never identify my practice location beyond a fairly wide swath of the Pacific NW. I actually ran this blog by my hospital's compliance department a few years ago and got their blessing. (I want to keep my job)

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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